Laserfiche WebLink
10/27/2000 09:34 7146 26754 EAI 0 <br /> PAGE 03 <br /> San JoegUin COunty Environmental Health Services,Unit IV Well Permit Appliic�a/'tion S�uuppppleMent <br /> JOB ADDRESS: Sain Joaquin Delta _C011ege PERMIT 5R# lJ6 ( 6 <br /> 5151 Pacific Avenne <br /> Stockton, California <br /> LICENSED CONTRACTORS DECLARATION (LCD) <br /> I hereby affirm that I em lieensed under the provlslons of Chapter 9(Commencing with Section 7000)of Division <br /> 3 of the Business and Professions Code and my license is in full force and effect. <br /> Llcansa fir__ � 21��� Expiration Date: In ! ':�t! In ! <br /> Date: actor: 1,rs aory� � <br /> V — <br /> Signature: Title:_ if•C�_ Pr�� ' �p „ —�. <br /> Printed name: e'—t, f•'S 1S �lti <br /> WORKERS' COMPENSATION DECLARATION <br /> I hereby affirm under penalty of perjury one offhe following declarations: (CHECK ALL THAT APPLY) <br /> I have and will maintain a cartlltcate of consent to self-Insure for workers'compansation,as provided for by <br /> Section 3700 of the Labor Code, for the performance of the work for which this permit Is issued. <br /> t have and will maintain workers'compersa4on insurance, as required by Section 3700 of the Lahor Code, <br /> for the performance of the work for which this permit is issued. My workers'compensation insurance <br /> carrier and policy numbers are <br /> Carrier. IW—:-"� Policy Number: <br /> 100Y that In the performance of Ihs work for which this permit is issued, I shall not employ any person In <br /> any manner so a$to become Subject to the workers'oompensation laws of California, and agree that if I <br /> should become subject to the workers'compensation provisions of Section 3700 of the Labor Code, I shall <br /> forthwith Comply with Those provisions. <br /> Date: jh- $(,L��Signature:. <br /> Printed Name:—4� <br /> WARNING:FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE 13 UNLAWFUL,AND SHALL SUBJECT <br /> AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES Up TO ONE HUNDRED THOUSAND DOLLARS <br /> ($100,000.),IN ADDITION TO THE COST OF COMPENSATION,INTEREST,ATTORNEY'S FEES,AND DAMAGES AS <br /> PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE. <br /> l'�P�' `�-�^ ���tc� (C•57 licensed authorimtl reproaentaWo),hereby <br /> LLhe .s San Joaquin County Well Permit Application on my behalf. 1 understandthus autheHzation Is valid{or <br /> r end Is limited to the work plan dated on the front page of this application. <br /> MI <br /> E abed `00:01 00-0E-100 `•ZOEO ElC 5Z6 `• 'auI 'butlsal 3 5UTTTTJO 56aJq :/g }uag <br />